Federal Survey Data on Tobacco: It’s Not About The Children

I have documented for several years a nonstop decline in smoking rates among American teens (here, here, here, and here  )

Rates of smoking and use of other tobacco products among teens are so low that they no longer provide a valid basis for the draconian anti-tobacco policy prescriptions favored by the FDA and CDC. 

A fresh National Survey on Drug Use and Health summary (here) confirms low tobacco use by teens.  The chart at left shows that the smoking rate continued its free-fall through 2013.  Cigar use also declined over the past decade to 2.3% in 2013, while smokeless tobacco use was flat at about 2% over the entire period.

These figures aren’t underestimates.  As I discussed previously (here), NSDUH estimates tend to be robust because they include any product use over the prior 30 days. 

 

Other NSDUH data (in the second chart) point to the population that should be targeted by the FDA and CDC – those aged 18-34.  The sharp jump in smoking prevalence from 11% at ages 16-17, to 27% at ages 18-20, underscores that the latter group is where the real problem starts. 

Anti-tobacco forces know that problematic behaviors in adults don’t stimulate support for prohibitionist policies, so they continue to inaccurately suggest the existence of a youth-tobacco crisis.  

The True Impact of Snus in Sweden: Smoking Cessation Up, Initiation Down

It is a widely accepted myth that snus use among men in Sweden has only served as a quit-smoking aid. While my published studies from 2002 to 2005 (described here, here, and here) and many others (here, here, and here) have documented that male smokers in Sweden have used snus as a gateway to a smoke-free life, that is only part of the story.

Snus use has also played a valuable role in steering tobacco initiators away from more dangerous cigarettes. In 2005, I authored a study of tobacco use among Swedish boys and girls age 15-16, which was published in Tobacco Control (here). The results are impressive: “During the period 1989 to 2003, the prevalence of tobacco use [in Sweden] declined both among boys and girls. For boys, regular smoking declined after 1992 from 10% to 4%. Their snus use was about 10% in the 1990s but increased to 13% by 2003. Regular smoking among girls was 20% in early years and declined to 15%. Smoking among girls was always double that among boys. Patterns of occasional tobacco use were similar to those of regular use.”

I also observed that “…specific patterns of tobacco use differ strikingly between Swedish boys and their EU counterparts…In 2002 the World Health Organization reported that the average prevalence of daily smoking among 15 year old boys in 25 European countries (excluding Sweden) was 18%.7. In that report boys in Sweden had the lowest smoking prevalence of all countries (5.7%), at about one third of the EU average. The next highest prevalence was in Greece (9.2%). All other countries reported prevalences from 12% (Wales) to 27% (Lithuania). Thus, high prevalence of snus use by Swedish boys may be a factor in low smoking prevalence.

“In contrast, smoking rates among 15 year old girls in Sweden do not differ from those among girls in other European countries. In the 2002 WHO report smoking prevalence among Swedish girls was the fifth lowest in Europe (14%), but still close to the average for all other countries (19%, range 11% in Greece to 29% in Germany).”

I want to be absolutely clear: I strongly support all measures to keep tobacco away from children. However, a tobacco-free world, for adults and children, is as likely as an alcohol-free world was in 1920 (here). Teenagers will use tobacco, no matter what measures are taken to stop them. The remarkable story from Sweden is that most boys choose snus, the product their fathers use. This fact is well-received by health and policy professionals who understand that snus users lead lives that are virtually indistinguishable (in measures of years and health) from those of their abstinent peers.

Finally, the “Swedish Snus Experience” is not only about men. Recently, more women in Sweden are also using modern snus products (evidence here), which are spit-free and socially acceptable. This may represent the first time in recorded history that women have adopted a healthier behavior – from their husbands.

Terrific News From Tobacco Retail Inspections in Indiana and Mississippi

Last week the Indiana Tobacco Retailers Inspection Program announced that 96% of tobacco retailers in the state were compliant with laws restricting tobacco products to minors (story here). This is the highest compliance rate since the program’s inception in 2000, when the rate was 59%.

Indiana’s outstanding results are similar to those from FDA compliance checks in Mississippi, announced in early January by the agency (here). Of the 493 Mississippi tobacco retailers that were inspected, only 25 had violations. In other words, 95% of stores in that state are not selling tobacco to minors. This compliance rate is much higher than even a few years ago. To the agency’s credit, FDA issued stern warning letters to the remaining violators.

I have been critical in the past of FDA Center for Tobacco Products actions (here, here and here), but these are positive developments. Point-of-sale is a legitimate place for enforcement actions by state and federal agencies. The FDA indicates that it will expand the compliance checks to all 50 states during the upcoming fiscal year.

Still, these actions will have little impact on major suppliers of tobacco to underage users -- adult friends or relatives who legally purchase tobacco products and then provide them to teens. According to a study published in 2004, (abstract here), 65% of teen smokers obtained cigarettes in just that way. That is probably why the 2010 Monitoring the Future Survey found that 75% of 10th graders reported that it was "fairly easy" or "very easy" to get cigarettes.

Stopping underage access to tobacco is a critical national priority, but non-compliant retailers are no longer a significant source for teenagers. This key fact invalidates the allegation by Matt Myers and other zealots that tobacco manufacturers are targeting kids with harm reduction products like dissolvables (here). The allegation is fatuous if children don’t have access to tobacco products.

Camel Dissolvables and Anti-Tobacco Dissembling

On December 20, R.J. Reynolds Tobacco Company announced that it was discontinuing Camel Dissolvable test marketing in Indianapolis, Columbus, Ohio and Portland, Oregon (here). The response from Matthew Myers (here), president of the Campaign for Tobacco-Free Kids, speaks volumes about the U.S. anti-tobacco crusade’s faulty logic.

According to Myers, “The Camel dissolvable products appeal to children in that they are easily concealed and colorfully packaged, shaped and flavored to resemble mints or gum.” He ignores the fact that dissolvables are tobacco products and are thus subject to a complete sales prohibition to anyone under 18 years in all 50 states.

Myers also blamed tobacco manufacturers for an increase in smokeless tobacco use by children: “Most troubling, the most recent data on youth tobacco use, included in the Monitoring the Future Survey released just last week, shows a significant increase in smokeless tobacco use among high school students. Among 12th graders, 8.5 percent used smokeless tobacco in 2010, a 39 percent increase since 2006…The increase in smokeless tobacco use also comes as some smokeless manufacturers have sought to portray their products as a less hazardous alternative to cigarettes.”

Myers’s use of the Monitoring the Future Survey was very creative. Why use 2006 as a comparison year? Because in 2006, smokeless tobacco prevalence was unusually low – in fact, the lowest in the 25-year history of the survey. This makes the 8.5 percent prevalence in 2010 seem like a substantial increase. Actually prevalence was 8.4% in 2009 and 1999, and even higher before that.

It is disingenuous for Myers to blame manufacturers for tobacco use by teenagers. While it’s true that 8.5% of 12th graders used smokeless tobacco and 19.2% smoked cigarettes in 2010, 21.4%, smoked marijuana. What industry does Myers hold responsible for marijuana use among children?

Teenage substance use fluctuates, which permits zealots to cherry-pick findings for dramatic, but highly misleading, story lines. If tobacco use is down, zealots take credit; if tobacco use rises, they blame industry.

Gandhi said an error does not become truth by reason of multiplied propagation, nor does truth become error because nobody sees it. Tobacco opponents continue to dissemble on harm reduction and the risks associated with smokeless tobacco. But the facts endure, and they will continue to sustain a transformation in nicotine and tobacco use.

Tobacco Harm Reduction in the New York Times

On January 31, the New York Times published an article on tobacco harm reduction written by Duff Wilson and Julie Creswell. It focused on a series of submissions to the FDA by Altria, the parent corporation of Philip Morris and U.S. Smokeless Tobacco.

The article suggests that Altria’s argument for FDA endorsement of tobacco harm reduction is a cynical and insincere strategy: “…by focusing the F.D.A.’s attention on smokeless products, a much smaller but growing industry, Altria and other tobacco companies are diverting regulators’ attention from the source of the real public health problem: cigarettes.”

This post takes a critical look at the Times article.

The piece describes Altria as a “corporate pariah blamed for the deaths of millions of people,” noting that cigarette smoking is addictive and causes disease. Altria and other cigarette manufacturers have acknowledged these facts; they believe that the FDA should oversee a program that fully informs smokers about safer smokeless options.

Tobacco prohibitionists were quoted in the article. Stanton Glantz (University of California at San Francisco): “If you look at how they’re marketing smokeless now, they’re marketing for dual use, and to protect the cigarette market, which is their big money maker.”

By this, Glantz acknowledges that manufacturers are marketing smokeless tobacco to smokers. But Glantz seems to believe that Altria has power to “protect the cigarette market” by keeping smokers from switching entirely to smokeless tobacco. If smokers are informed that smokeless products are vastly safer, many will switch, significantly reducing the 400,000 smoking-related deaths that occur in the U.S. annually.

Gregory Connolly (Harvard University): “[Altria is] taking the FDA debate and making it on smokeless rather than ‘light’ cigarettes, which is where the real harm is.”

Kudos to Connolly for implicitly acknowledging that there is no “real harm” in smokeless tobacco. That is precisely why Altria wants FDA permission to tell smokers the truth.

Wilson and Creswell report that Matthew Myers (Campaign for Tobacco-Free Kids) “argues that there is no evidence that smokeless products are effective tools to help people quit smoking.”

This is utter nonsense. Smokeless tobacco is established as a gateway to smoking cessation for men and women in Sweden, and in Norway. In 2008, I provided the first population-level evidence that American men have quit smoking by switching to smokeless tobacco. Using data from the 2000 National Health Interview Survey, which the CDC uses to estimate smoking prevalence in the U.S., Carl Phillips and I estimated that 359,000 American male smokers had tried to quit by switching to smokeless, and 73% (261,000) were successful, the highest percentage of all methods. In comparison, the nicotine patch was tried by 2.9 million smokers, but only 35% were successful. Of the 964,000 smokers who tried nicotine gum, only 34% succeeded.

As I predicted in an earlier post, Kenneth Warner (University of Michigan) attacked the use of flavors in smokeless tobacco products: “The flavors are designed to attract kids.”

This may be evidence of an overzealous imagination. Tobacco manufacturers are prohibited by law from marketing to children. But prohibitionists are adept at making draconian policies seem palatable by pitching them as “protecting children.” Prohibitionists promote a flavor ban because they know that unflavored smokeless products won’t appeal to many smokers. Banning all flavors in smokeless tobacco makes about as much sense as banning flavors in alcoholic beverages.

Wilson and Creswell avoided discussion of the scientific and medical issues in Altria’s FDA submission, instead focusing on the shrill complaints of tobacco prohibitionists. I suggest that you read the documents, available here; they are accurate and based on scientific and medical literature. I also invite you to read my FDA submission, entitled “Tobacco Harm Reduction: Medical, Scientific and Public Health Rationale”.